What to Do When You Don't Qualify for Medicare

What are your other options?

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Not everyone who turns 65 years old necessarily qualifies for Medicare. Many with disabilities may even be turned down for benefits. This leaves many Americans without easy access to health care. What options can you fall back on when you don't make the cut?

Understanding Medicare Eligibility

Medicare eligibility is black and white. You either meet criteria or you don't. The U.S. government requires that you meet at least one criteria in each of these two categories.

  1. Citizenship and/or Legal Residency: You must be a U.S. citizen or a legal resident with a Green Card for a minimum of five years. To apply for Medicare, legal residents must have also lived in the U.S. for the five years immediately preceding their application.
  2. Health status: You must prove that you are in medical need. Since we are at higher risk for health issues as we get older, age is one criterion. Medicare sets the eligibility age at 65 years old. Alternatively, you may qualify based on a disability that is recognized by the Social Security Administration and/or the Railroad Retirement Board.

If you do not meet criteria in both categories, you will need to find an alternative insurance source. 

People Who May Not Have Medicare Access

Legal residents tend to find themselves in trouble when it comes to the calendar. It may be that they have not been in the country long enough to meet the timeline criteria.

Some people may have lived in the country longer than five years but do not have legal residency. The clock to Medicare eligibility does not start ticking until they have their official Green Card in hand. It doesn't matter if they are already 65 years old.

People with disabilities may also find themselves between a rock and a hard place.

Someone on Social Security Disability Insurance (SSDI) is not eligible for Medicare until they have been on SSDI for 24 months. That leaves two years when they need to seek out other healthcare options.

More tricky for those on SSDI is how to decide between Medicare and those healthcare alternatives once they are finally eligible. Since many people with disabilities are not 65 years old, they may think they do not need to sign up for Medicare right away. An Obamacare plan, for example, may be cheaper for them. The law states, however, that you cannot be on Obamacare and be Medicare eligible at the same time. If you turn down Medicare for another health plan, you will lose your Social Security disability benefits.

Know Your Non-Medicare Health Care Options

Learning that you don't qualify for Medicare is difficult—the news can create an emotional and financial burden. Before you panic, explore these options. They'll provide you with the coverage and peace of mind you need. 

  • Private Insurance Plans: You purchase these plans directly from private insurance companies. Rates may be based on your age with coverage costing more the older you get. Take note that private insurers are not allowed to sell to anyone who is eligible for Medicare.
  • Employer-Sponsored Health Plans: If you or your spouse are currently employed, this may be your best bet. Your employer may be able to sponsor insurance for you that keeps your costs down. You will pay far less than you would if you paid for the same private health plan all on your own.
  • Health Insurance Marketplace (Obamacare): The Affordable Care Act enacted Obamacare in 2010. The Health Insurance Marketplace, however, did not take effect until 2014. This opened up a number of health plans to Americans at affordable rates, at least lower rates than many private health plans. The Marketplace covers individuals with incomes between 100 and 400 percent of the Federal Poverty Level (FPL). FPL standards are set each year by the government. As noted earlier, you cannot apply for Obamacare if you are eligible for Medicare.
  • Medicaid: You may be eligible for Medicaid even if you are not eligible for Medicare. In some cases, you may be eligible for both. Though both programs are regulated by the Centers for Medicare and Medicaid Services (CMS), they have different eligibility criteria. Medicaid is intended to assist those with lower incomes. Depending on the state you live in, criteria may be vary. The Affordable Care Act, however, requires that anyone earning less than 138 percent of the FPL will be eligible for Medicaid.
  • Program of All-Inclusive Care for the Elderly (PACE): This program is available to anyone 55 years and older who has health issues that may require nursing home level care. The goal of PACE, however, is to actually keep you in your home as long as possible. To take advantage of these benefits, you need to live in a PACE service area. At this time, PACE programs are available in 31 states.

Where Can You Turn?

If you are still unsure of your options, you may want to reach out to a State Health Insurance Assistance programs (SHIP) in your state. These are volunteer-run organizations that may be able to point out available options in your area.


Healthcare.gov. Get Coverage for Individuals and Families. https://www.healthcare.gov/get-coverage/. Accessed May 3, 2016.

Medicaid.gov. How Can I Apply for Coverage? https://www.medicaid.gov/apply-for-coverage/apply-for-coverage.html. Accessed May 3, 2016.

National PACE Association. Find a PACE Program in Your Neighborhood. http://www.npaonline.org/pace-you/find-pace-program-your-neighborhood. Accessed May 3, 2016.

Obamacare Facts. Sign Up For ObamaCare: ObamaCare Sign up Deadlines. http://obamacarefacts.com/obamacare-sign-up. Accessed May 3, 2016.

U.S. Department of Health and Human Services. Poverty Guidelines. https://aspe.hhs.gov/poverty-guidelines. Published January 25, 2016. Accessed May 3, 2016.

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